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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - a stroke as those who had not been scanned.36 This finding suggests that clinicians were correctly identifying … Non-contrast brain CT scan has extremely poor sensitivity for identifying TIA or early ischemic strokes
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - a stroke as those who had not been scanned.36 This finding suggests that clinicians
were correctly identifying … Non-contrast brain CT scan has extremely poor sensitivity for identifying TIA or early ischemic
strokes
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - stroke as those who had not been scanned. 36 This finding suggests that clinicians were correctly identifying … Non-contrast brain CT scan has extremely poor sensitivity for identifying TIA or early ischemic strokes
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - – Protecting the patient’s safety in this case involved identifying and
implementing measures to
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - like CMQCC’s vaginal birth initiative, CMQCC leaders say that it is important to start with clearly identifying
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - Protecting the patient’s safety in this case involved identifying and implementing measures to protect
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - passive stretch of the compartment should prompt investigation for possible compartment syndrome. 20
Identifying
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psnet.ahrq.gov/node/43723/psn-pdf
October 03, 2017 - Shining a Light: Safer Health Care Through Transparency.
October 3, 2017
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
https://psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency
Health care has historically treated data as something to be safeguarded rat…
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psnet.ahrq.gov/node/45893/psn-pdf
August 28, 2017 - Exploring the roots of unintended safety threats
associated with the introduction of hospital ePrescribing
systems and candidate avoidance and/or mitigation
strategies: a qualitative study.
August 28, 2017
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended safety threats associated with
…
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psnet.ahrq.gov/node/74050/psn-pdf
November 10, 2021 - Health disparities: impact of health disparities and
treatment decision-making biases on cancer adverse
effects among black cancer survivors.
November 10, 2021
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-
making biases on cancer adverse effects among …
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psnet.ahrq.gov/node/60202/psn-pdf
April 08, 2020 - Use of an electronic clinical decision support system in
primary care to assess inappropriate polypharmacy in
young seniors with multimorbidity: observational,
descriptive, cross-sectional study
April 8, 2020
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an electronic clinical decision support
…
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psnet.ahrq.gov/node/39082/psn-pdf
January 04, 2010 - Communication practices on 4 Harvard surgical
services: a surgical safety collaborative.
January 4, 2010
Elbardissi AW, Regenbogen SE, Greenberg CC, et al. Communication practices on 4 Harvard surgical
services: a surgical safety collaborative. Ann Surg. 2009;250(6):861-5.
doi:10.1097/SLA.0b013e3181afe0db.
https:…
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psnet.ahrq.gov/node/45491/psn-pdf
May 09, 2017 - A systematic review of the types and causes of
prescribing errors generated from using computerized
provider order entry systems in primary and secondary
care.
May 9, 2017
Brown CL, Mulcaster HL, Triffitt KL, et al. A systematic review of the types and causes of prescribing errors
generated from using computerize…
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psnet.ahrq.gov/node/41027/psn-pdf
September 01, 2016 - Clinical decision support systems could be modified to
reduce 'alert fatigue' while still minimizing the risk of
litigation.
September 1, 2016
Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to
reduce 'alert fatigue' while still minimizing the risk of litigation…
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psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014.
December 20, 2017
Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201.
https://psnet.ahrq.gov/issue/us-emergenc…
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psnet.ahrq.gov/node/42144/psn-pdf
March 27, 2013 - Usability of a computerised drug monitoring programme
to detect adverse drug events and non-compliance in
outpatient ambulatory care.
March 27, 2013
Auger C, Forster AJ, Oake N, et al. Usability of a computerised drug monitoring programme to detect
adverse drug events and non-compliance in outpatient ambulatory ca…
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psnet.ahrq.gov/node/40963/psn-pdf
November 30, 2011 - Association between Leapfrog safe practices score and
hospital mortality in major surgery.
November 30, 2011
Qian F, Lustik SJ, Diachun CA, et al. Association between Leapfrog safe practices score and hospital
mortality in major surgery. Med Care. 2011;49(12):1082-1088. doi:10.1097/MLR.0b013e318238f26b.
https://ps…
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psnet.ahrq.gov/node/42969/psn-pdf
October 31, 2014 - Reducing the burden of surgical harm: a systematic
review of the interventions used to reduce adverse events
in surgery.
October 31, 2014
Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the
interventions used to reduce adverse events in surgery. Ann Surg. 2014;2…
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psnet.ahrq.gov/node/43323/psn-pdf
January 07, 2015 - Unrealized potential and residual consequences of
electronic prescribing on pharmacy workflow in the
outpatient pharmacy.
January 7, 2015
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic
prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inf…
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psnet.ahrq.gov/node/47104/psn-pdf
December 04, 2018 - Deriving a framework for a systems approach to agitated
patient care in the emergency department.
December 4, 2018
Wong AH, Ruppel H, Crispino LJ, et al. Deriving a Framework for a Systems Approach to Agitated Patient
Care in the Emergency Department. Jt Comm J Qual Patient Saf. 2018;44(5):279-292.
doi:10.1016/j.j…